High degree of consensus on diagnosis and management of rotator cuff tears: a Delphi approach

Abstract

Purpose To develop a consensus on diagnosis and treatment of rotator cuff tears. The study focused on selected areas: imaging, prognostic factors, treatment options, surgical techniques. Methods Panel was composed of all members of the shoulder committee of the Italian Society of Arthroscopy, Knee, Upper arm, Sport, Cartilage and Orthopedic techniques (SIAGASCOT). Four rounds were performed. The first round consisted of gathering questions which were then divided into seven blocks referring to: imaging, patient‐related prognostic factors, treatment options, surgical steps, reparative techniques, surgical predictive factors, advanced techniques. Subsequent rounds consisted of condensation by means of online questionnaire and debates. Consensus was defined as two‐thirds agreement on one answer. Descriptive statistic was used to summarize the data. Results Forty‐one shoulder experts were involved. Fifty‐six statements were finally formulated. A consensus could be achieved on 51. Experts agreed that preoperative magnetic resonance imaging is strongly recommended because it allows a careful evaluation of tear characteristics, while the role of US remains debatable. Controversial patient‐related factors such as age, comorbidities, smoking and stiffness do not contraindicate the repair. From a surgical standpoint, the experts highlighted that pseudo‐paralysis is not a contraindication to rotator cuff repair. Consensus on specific surgical steps was also achieved: capsular release should be performed only in stiff shoulders; footprint preparation is mandatory, while debridement of tendon edges is not essential. If necessary, a rotator interval release could be performed without interrupting the continuity between subscapularis and supraspinatus tendon; posterior delamination should be always included in the repair. Advanced techniques such as tendon transfers should be selected based on the main clinical deficit, while the superior capsule reconstruction plays a role only in combination with a functional repair. Conclusion A consensus was achieved almost on every topic of controversy explored. Particularly, MRI was deemed necessary to determine tear characteristics, while radiographs remain important for differential diagnosis; age should not be considered a contraindication to surgery; pseudo‐paralysis does not represent a contraindication to arthroscopic rotator cuff repair, but superior capsule reconstruction plays a role only in combination with a functional repair. Latissimus dorsi transfer plays a role when the main functional deficit is in elevation, while the lower trapezius transfer plays a role when the main functional deficit is the external‐rotation. Level of evidence V.

A modified Patte classification system for rotator cuff tendon retraction to predict reparability and tendon healing in arthroscopic rotator cuff repair

“…Therefore, a reliable method to predict the possibility of irreparability and healing failure after ARCR would help surgeons plan surgical procedures and counselling patients [31,45]. Notably, many studies have identified that retraction of the rotator cuff tendon, determined by preoperative magnetic resonance imaging (MRI), is crucial in predicting reparability and tendon healing after ARCR [1,6,11,19,21,34,37,38].…”

Delamination of rotator cuff tears impairs healing after repair: a systematic review and meta‐analysis

“…The other method is a layered suture under arthroscopy, which adheres to the original anatomical structure of the rotator cuff by separately fixing the synovial sac of the rotator cuff and the lateral aspect of the joint. No significant difference was observed between separate and en bloc repairs [11, 12], it is unclear if tendon delamination affects rotator cuff repair healing and clinical outcomes. Delamination is a risk factor for poor clinical and anatomical outcomes after rotator cuff repair [2, 13, 14].…”